Secure Referral | My Therapy Space

Section 1: Your Details (Optional)

Leave these fields blank if you wish to remain completely anonymous.

Your Name

Relationship to Client

Section 2: Referred Individual

Client Name *

Client Age / DOB

Client Email *

Client Phone Number

Section 3: Referral Context

Reason for Referral *

Please provide a brief overview of why support is being sought.

Service Requested (If Known)

Section 4: Outreach Preference

Notify the client on my behalf (Anonymous) We will send an automated, discreet email to the client letting them know they have been recommended to My Therapy Space, providing a link to book a consultation. Your identity will remain hidden.

Do not contact the client We will log this referral securely. The client must reach out to us independently, or we will wait for further contact.

I confirm that the referred individual is aware of this referral and consents to their data being shared with My Therapy Space. *

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